Pediatric Patient Surge: Evaluation of an Alternate Care Site Quality Improvement Initiative.

BACKGROUND: Pediatric Level I trauma centers often experience patient volume surges. The increase stresses the emergency department, and usual patient care areas become inadequate. The purpose of this quality improvement study is to describe the implementation and analysis of an alternate care site to facilitate patient flow during seasonal patient volume surges. METHODS: This initiative used a nonequivalent historical control group posttest-only design. An alternate care site was selected because of its size, temporary nature, low cost, and proximity to the emergency department. The alternate care site was activated between January and March 2019 using the following criteria: the total number of patients in waiting room 30 or more and wait times 2.5 hr or more. Outcome metrics include total census, length of stay-admissions, length of stay-discharges, left without being seen, hours per patient visit, patient satisfaction scores, and process metrics. Descriptive statistics and t tests were used to determine differences between groups. RESULTS: A total of 180 patients were analyzed with n = 90 from 2018 and n = 90 from 2019. The alternate care site was activated five times over one season. The alternate care site decreased median waiting times, length of stay-admissions, length of stay-discharges, and left without being seen as compared with the previous year. Hours per patient visit and patient satisfaction scores remained constant as compared with the previous year. CONCLUSIONS: The creation of an alternate care site within the emergency department allowed quick mobilization, response, and treatment of patients. The alternate care site decreased median length of stay for admissions, discharges, and who left without being seen while keeping hours per patient visit and patient satisfaction constant. Future studies should confirm findings by testing the alternate care site in other hospitals and settings and should consider formally evaluating staff satisfaction.

Comparison of a rapid albuterol pathway with a standard pathway for the treatment of children with a moderate to severe asthma exacerbation in the emergency department.

OBJECTIVE: The objective of this study was to determine if a rapid albuterol delivery pathway with a breath-enhanced nebulizer can reduce emergency department (ED) length of stay (LOS), while maintaining admission rates and side effects, when compared to a traditional asthma pathway with a standard jet nebulizer. METHODS: Children aged 3-18 presenting to a large urban pediatric ED for asthma were enrolled if they were determined by pediatric asthma score to have a moderate to severe exacerbation. Subjects were randomized to either a standard treatment arm where they received up to 2 continuous albuterol nebulizations, or a rapid albuterol arm where they received up to 4 rapid albuterol treatments with a breath-enhanced nebulizer, depending on severity scoring. The primary endpoint was ED LOS from enrollment until disposition decision. Asthma scores, albuterol dose, side effects, and return visits were also recorded. RESULTS: A total of 50 subjects were enrolled (25 in each arm). The study LOS was shorter in the rapid albuterol group (118 vs. 163 minutes, p = 0.0002). When total ED LOS was analyzed, the difference was no longer statistically significant (192 vs. 203 minutes, p = 0.65). There were no statistically significant differences with respect to admission rates, asthma score changes, side effects, or return visits. CONCLUSION: A rapid albuterol treatment pathway that utilizes a breath-enhanced nebulizer is an effective alternative to traditional pathways that utilize continuous nebulizations for children with moderate to severe asthma exacerbations in the ED.

A randomized trial of Plasma-Lyte A and 0.9 % sodium chloride in acute pediatric gastroenteritis.

BACKGROUND: Compare the efficacy and safety of Plasma-Lyte A (PLA) versus 0.9 % sodium chloride (NaCl) intravenous (IV) fluid replacement in children with moderate to severe dehydration secondary to acute gastroenteritis (AGE). METHODS: Prospective, randomized, double-blind study conducted at eight pediatric emergency departments (EDs) in the US and Canada (NCT#01234883). The primary outcome measure was serum bicarbonate level at 4 h. Secondary outcomes included safety and tolerability. The hypothesis was that PLA would be superior to 0.9 % NaCl in improvement of 4-h bicarbonate. Patients (n = 100) aged ≥6 months to <11 years with AGE-induced moderate-to-severe dehydration were enrolled. Patients with a baseline bicarbonate level ≤22 mEq/L formed the modified intent to treat (mITT) group. RESULTS: At baseline, the treatment groups were comparable except that the PLA group was older. At hour 4, the PLA group had greater increases in serum bicarbonate from baseline than did the 0.9 % NaCl group (mean ± SD at 4 h: 18 ± 3.74 vs 18.0 ± 3.67; change from baseline of 1.6 and 0.0, respectively; P = .004). Both treatment groups received similar fluid volumes. The PLA group had less abdominal pain and better dehydration scores at hour 2 (both P = .03) but not at hour 4 (P = 0.15 and 0.08, respectively). No patient experienced clinically relevant worsening of laboratory findings or physical examination, and hospital admission rates were similar. One patient in each treatment group developed hyponatremia. Four patients developed hyperkalemia (PLA:1, 0.9 % NaCl:3). CONCLUSION: In comparison with 0.9 % NaCl, PLA for rehydration in children with AGE was well tolerated and led to more rapid improvement in serum bicarbonate and dehydration score. TRIAL REGISTRATION: NCT#01234883 (Registration Date: November 3, 2010).

Utility of a child abuse screening guideline in an urban pediatric emergency department.

BACKGROUND: Previous studies have found racial and socioeconomic status bias in the way clinicians screen for and detect child abuse in patients presenting to the emergency department. We hypothesized that implementing a guideline for screening would attenuate this bias. METHODS: An algorithm for child abuse screening in patients younger than 1 year presenting with fractures was developed for a pediatric trauma center emergency department. Data were collected 1.5 years before and after implementation of the algorithm to investigate implementation success. Data were compared before and after the implementation of the algorithm using χ and univariate logistic regression analysis. RESULTS: The characteristics of patients with fractures were similar before and after the algorithm implementation. Implementation of the algorithm was related to a significant increase in algorithm required screenings: skeletal survey (p < 0.001), urinalysis (p < 0.001), and transaminase levels (p < 0.001). The racial composition of those screened did not change after the implementation of the protocol. Children with government-subsidized or no insurance were more likely to be screened for child abuse via skeletal survey before the algorithm implementation compared with those with private insurance (odds ratio, 2.7; 95% confidence interval, 1.2-6.0; p = 0.017). This relationship did not exist after the algorithm implementation (odds ratio, 1.2; 95% confidence interval, 0.56-2.46; p = 0.66). Final determination of child abuse was related to insurance status both before and after the algorithm implementation. CONCLUSION: A child abuse screening algorithm was successfully implemented in an urban trauma center. After implementation, screening was no longer associated with socioeconomic status of the patient's family, although final determination of child abuse still was. Additional research is needed to determine utility of unbiased screening on patient outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Comprehensive pain management protocol reduces children's memory of pain at discharge from the pediatric ED.

BACKGROUND: Historically, pain has been poorly managed in the pediatric emergency department (ED) (PED), resulting in measurable psychosocial issues both acute and delayed. OBJECTIVE: The aim of the study was to measure the impact of protocolized pain management on patients with painful conditions or undergoing painful procedures in the PED. METHODS: We performed an analysis before and after the implementation of the protocol, dubbed the "Comfort Zone." Validated, age-appropriate pain scales were performed. Validation (using Cronbach α, confirmatory factor analysis) was followed by comparison of responses between the pre- and posttests collected (χ(2) and Wilcoxon rank sum tests). Pain scores were collected at triage and at discharge. At triage, patients were asked to report pain levels. At discharge, they were asked to report their current pain and recall the level of pain during their stay. At triage, parents were asked to report about their perception of the child's pain. At discharge, they were asked to report about their perception of the child's current pain and recall the level of pain during the stay and during procedures, if done. RESULTS: Five hundred thirty-one patients were enrolled in the preprotocol group; 47% were women with a median age of 5 years (range, 30 days-18 years). Two hundred sixty-three patients were enrolled in the protocol group; 39% were women with a median age of 6 years (range, 30 days-18 years). Patient-recalled pain scores of the ED visit in the protocol group were significantly lower than those of the preprotocol group (Wong-Baker Faces Pain Scale, 5.07-4.01; P < .001); yet parent estimates of pain did not show a significant change at any point. Patient assessment of pain at ED discharge did not show a significant change either (Wong-Baker Faces Pain Scale, 1.99-1.56; P = .09). The Faces scale is not well validated for patients younger than 4, so that group had only parental assessment of pain and, consistent with the larger data set, showed no significant pain scale reduction at any point. CONCLUSION: Protocolized pain management reduces patients' memory of pain during PED visits but may not affect parental memory of perceived pain or parent- and patient-reported pain at discharge.